Utility of Asymmetric Multilevel Pontes Osteotomy in Ankylosing Spondylitis with Scoliosis using Ultrasonic Bone Scalpel: Case Report.

Introduction: Ankylosing spondylitis is a spondyloarthropathy that commonly involves the axial skeleton with predilection to the sacro-iliac joints and spine. The disease frequently results in a smooth globular kyphotic deformity of the spine; however, a coronal plane scoliotic deformity is extremely rare. We present a unique case of scoliotic deformity in a patient diagnosed with ankylosing spondylitis. To the best of our knowledge, following a review of the literature, this appears to be the first report of this kind. Case Report: A 23-year-old male patient presented with chronic back pain, stiffness, and a truncal shift of the body. He had a rigid left-sided thoracolumbar curve measuring 41° with a coronal imbalance of 3.6 cm. We present a case report on scoliosis deformity correction performed with a four-level asymmetric pontes osteotomy using a bone scalpel with excellent correction of the scoliotic deformity that was well maintained at 2-year follow-up. Conclusion: Scoliosis in ankylosing spondylitis has not been documented in literature. We report the complete correction of the deformity, which is well maintained at the 2-year follow-up.

Functional Outcome of Mechanical Alignment in Total Knee Arthroplasty Surgery: A Short-Term Cohort Study at an Indian Tertiary Care Hospital.

Background: In severe arthritis cases, goal of total knee arthroplasty (TKA) management is to attain pain-free joint and restore the overall limb alignment. There are limited short-term studies published from Indian hospitals that investigated the importance of neutral mechanical component alignment in TKA patients. Methods: Retrospective and prospective study was conducted at the Department of orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune from June 2020 to September 2022. Enrolled patients were assessed preoperatively and postoperatively using clinical examination, radiological assessment and functional outcomes through the Oxford knee score, Knee society score and VAS score. Results: 204 patients enrolled, and 267 knees were evaluated for the study. Osteoarthritis was the commonest diagnosis (254 knees, 95.13%). Pre-operatively, 92.13% knees were varus, 4.87% valgus and 3% neutral while post-operatively, 51.69% were varus, 16.1% were valgus, and 32.32% were with neutral axis. Majority of patients with a pre-operative neutral axis converted to varus axis (62.5%), while most valgus axis cases preoperatively converted to a neutral axis (53.84%). For pre-operative varus subgroup, the majority patients with < 10° pre-operative axis converted to neutral (41.28%). Majority patients with 10°-20° pre-operative axis remained varus (60.53%) and with > 20° pre-operative axis remained varus (78.26%). Functional outcome parameters were significantly improved at follow-up (P < 0.05). Conclusion: Short-term postoperative functional scores were significantly improved in postoperative cases, with the postoperative alignment of 0° ± 3° relative to the mechanical axis was achieved. Thus, postoperative neutral mechanical alignment of 0° ± 3° can be the standard of care for patients undergoing TKA.

Cervical Schwannoma camouflaged by cervical intervertebral disc prolapse-A case report.

INTRODUCTION: Cervical prolapsed intervertebral disc is one of the common conditions causing cervical myeloradiculopathy. Anterior Cervical Discectomy and Fusion (ACDF) is the standard line of management for the same. Intradural neurogenic origin tumors are relatively rare and can present with features of myeloradiculopathy. Radiological imaging plays important role in diagnosis of such pathologies. CASE REPORT: We report a patient with C5-6 cervical disc prolapse that presented with radiculopathy symptoms in the right upper limb, which was refractory to conservative care. He underwent a C5-6 ACDF and reported complete relief from symptoms at 4 weeks. He developed deteriorating symptoms over the next 10 weeks and presented at 14 weeks follow-up with severe myeloradiculopathy symptoms on the left upper limb with upper limb weakness. A fresh MRI identified an intradural extramedullary tumor with cystic changes at the index surgery level. This was treated with tumor excision and histopathology confirmed a diagnosis of schwannoma. Simultaneous presence of cord signal changes with disc herniation obscured the cystic schwannoma which became apparent later on contrast enhanced MRI imaging. CONCLUSION: Careful review of preoperative imaging and contrast MRI study may help in diagnosing cystic schwannomas with concomitant cervical disc herniations that have cord signal changes.

O-arm Navigated en bloc Excision of a Solitary Subaxial Cervical Osteochondroma Presenting as Myelo-radiculopathy: A Case Report.

Introduction: Vertebral osteochondroma is a rare entity. It presents with varied complaints ranging from palpable mass to myeloradiculopathy. En bloc excision is the gold standard treatment option for symptomatic patients. Real-time intraoperative navigation has increased the accuracy and safety of tumor excision. We report a case of cervical subaxial osteochondroma with myelo-radiculopathy, treated with excision, and monosegmental fusion under O-arm-based real-time navigation. Case Report: A 32-year-old male presented with complaints of axial neck pain with the right upper limb radiculopathy for 18 months. On examination, signs of myelopathy were identified without sensory-motor deficit. Magnetic resonance imaging and computed tomography scans were suggestive of solitary C6 osteochondroma compressing spinalcord. O-arm navigated en-bloc tumor excision with C5 hemilaminectomy and monosegmental fusion was done. Conclusion: The use of O-arm navigation aids in accurate intraoperative en bloc excision without any residual tumor and with better safety.

Low-volume ultrasound-guided supraclavicular block in a multicomorbid patient for emergency vascular surgery - In COVID-19 era.

Supraclavicular block is the most commonly used block in upper limb surgeries, right from the day it was introduced into clinical practice in Germany by Kulenkampff in 1911. The block underwent many changes in its application due to the advent of peripheral nerve stimulator and ultrasonographic application in regional anesthesia. This case report focuses on supraclavicular block's application in a multicomorbid patient, the drug dose required, and how the scope of regional anesthesia can be extended in times of pandemic, like coronavirus disease 2019 (COVID-19), in coming future.

Postoperative Pain Relief With Ultrasound-Guided Dorsal Sacral Foramen Block for Foot and Ankle Surgeries.

This case series describes the use of ultrasound (US)-guided dorsal sacral foraminal block (DSFB) for providing postoperative analgesia in six patients who underwent foot and ankle surgeries under spinal anesthesia. Postoperatively, all of them received a US-guided DSFB at the level of the brim of the second sacral foramina (SF2). Needle placements were confirmed with fluoroscopic (FL) images and injected radiocontrast defined the diffusion with a postoperative CT scan. The images obtained depicted ipsilateral spread in the sacral epidural space, sacral nerve roots, and plexus. The US-guided DSFB could be effectively used as an alternative method for postoperative pain relief after foot and ankle surgery.

Gluteal Contractions as a Gateway to Sacral Plexus.

Background Neurostimulation-guided sacral plexus blocks (SPBs) are primarily indicated for surgeries of the foot and ankle and secondarily for supplementing a lumbar plexus block for hip surgeries. Although ultrasound has largely replaced neurostimulation-guided SPB, it may not be available at all facilities. Hence, it is prudent to understand the intricacies of neurostimulation-guided SPB. Methodology In this study, 10 American Society of Anesthesiologists-physical status I and II patients undergoing an intramedullary femoral nail procedure for femoral fractures of the shaft femur received a combined lumbar and sacral plexus block for operative surgery and postoperative pain relief. Neurostimulation-guided SPB was administered in all patients after the lumbar plexus block. Results In all patients, gluteal contractions were observed as the stimulating needle advanced during neurostimulation-guided SPB, which was either a dorsal or plantar flexion. The end-point of neurostimulation-guided SPB was obtained at 1-1.5 mm beyond the gluteal contractions. Conclusions It is important to understand that gluteal contractions are evident as the needle is advanced and can be considered a gateway during a neurostimulation-guided SPB.

Impact and Outcomes of Regional Anesthesia Techniques in Elderly Patients With Fracture of Proximal Femur: A Retrospective Study.

Background Although subarachnoid block (SAB) is the most popular regional anesthesia (RA) technique for fixation of femur fractures, continuous lumbar epidural (CLE) anesthesia, and lumbosacral plexus blocks (LSPB) are also employed in specific situations. The choice of RA technique depends on either the choice of the anesthesiologist or based on the underlying comorbidities. At our institute, we anesthetize elderly patients who come for fixation of femur fracture with multiple comorbidities using RA techniques as mentioned based on comorbidities and overall general condition.  Methods In a cohort of 184 elderly patients, we analyzed RA techniques employed over a period of five years in elderly patients admitted with fractures of the proximal femur, its hemodynamic implications and thus attempted to find the suitable RA technique with minimal adverse events after ethics committee approval. We also compared the length of stay in the hospital in relation to RA techniques. Results The demographic data was comparable with no significant difference in administering the three RA techniques. SAB, CLE and LSPB was implemented at 33.33%, 35.96%, and 30.7% respectively. Perioperative noradrenaline infusion was a feature in patients who received SAB (p<0/001). The higher number of CLE and LSPB patients had a length of stay of fewer than 48 hours whereas most SAB patients had a length of stay of more than 48 hrs (p<0.001). Conclusion Elderly patients with multiple comorbidities should be offered CLE instead of SAB so as to maintain stable hemodynamics. RA technique in an elderly patient with multiple comorbidities should be standardized so as to provide uneventful surgical anesthesia.

Safety of apixaban in Indian patients undergoing elective total knee replacement or total hip replacement surgery: A multi-center, phase-IV study.

BACKGROUND: Venous thromboembolism is a significant source of morbidity and mortality following total hip replacement and total knee replacement. Apixaban has been proven to be efficacious without increased risk of bleeding in phase-III trials in patients undergoing total knee replacement and total hip replacement. Due to paucity of data on safety of apixaban in Indian patients, this phase-IV study was conducted to evaluate safety of apixaban in patients undergoing total knee replacement and total hip replacement. METHODS: In this non-comparative phase-IV clinical trial, patients undergoing elective total knee replacement or total hip replacement surgery, or a revision of at least one component of total knee replacement or total hip replacement, were enrolled. The eligible patients were given the approved dosage of apixaban 12 to 24 h after completing the skin wound closure. The primary safety outcome was the composite of the International Society on Thrombosis and Haemostasis-defined major bleeding and clinically relevant non-major bleeding events at the end of the treatment. The secondary efficacy endpoint was the composite of venous thromboembolism/all-cause death at the end of the treatment. RESULTS: A total of 498 patients received apixaban prophylaxis therapy. Six (1.2%) bleeding adverse events were observed during the treatment period. Only one bleeding event was adjudicated as an International Society on Thrombosis and Haemostasis-defined clinically relevant non-major bleeding event (moderate severity). There were no fatal bleeding events and no deaths following the treatment. One venous thromboembolism event, that is, symptomatic distal left leg DVT, was reported in a total knee replacement patient and was adjudicated during the treatment period. CONCLUSION: Apixaban demonstrated a favorable safety profile for venous thromboembolism prevention in Indian patients undergoing total knee replacement or total hip replacement.

Seymour's Fracture in a 13-years-old Child: A Case Report.

INTRODUCTION: A nail bed injury concomitant with an underlying physeal injury of the distal phalanx is termed as "Seymour's fracture." These are seemingly innocuous injuries commonly misdiagnosed and are subsequently under-treated. These injuries demand treatment like an open fracture to prevent complications such as infection, growth arrest, and nail dystrophies. CASE REPORT: A 13-year-old boy suffered Seymour's fracture of the left ring finger distal phalanx after a direct injury from a dodge ball. The fracture was treated with thorough debridement with normal saline, physeal injury reduction through the wound, and fixation with k-wire passed through the tip of the ring finger, metaphysic, physis, and the tip of the k-wire ending in the epiphysis of the distal phalanx. The nail bed was sutured with 3-0 monofilament absorbable sutures. The fracture healed at 3 months and a 1-year follow-up showed a completely formed nail without any deformity. CONCLUSION: Excellent outcome was observed with debridement of the wound, nail bed repair, and fixation with k-wire in our case. Nail bed injuries in children should be treated with a high index of suspicion for Seymour's fracture as it necessitates treatment like that of an open fracture to avoid complications.

Return to sport following anterior cruciate ligament reconstruction: the argument for a multimodal approach to optimise decision-making: current concepts.

Existing literature is varied in the methods used to make this determination in the treatment of athletes who have undergone recent anterior cruciate ligament (ACL) reconstruction. Some authors report using primarily time-based criteria, while others advocate for physical measures and kinematic testing to inform decision-making. The goal of this paper is to elucidate the most current medical evidence regarding identification of the earliest point at which a patient may safely return to sport. The present review therefore seeks to examine the evidence from a critical perspective-breaking down the biology of graft maturation, effect of graft choice, potential for image-guided monitoring of progression and results associated with time-based versus functional criteria-based return to play-to justify a multifactorial approach to effectively advance athletes to return to sport. The findings of the present study reaffirm that time is a prerequisite for the biological progression that must occur for a reconstructed ligament to withstand loads demanded by athletes during sport. Modifications of surgical techniques and graft selection may positively impact the rate of graft maturation, and evidence suggests that imaging studies may offer informative data to enhance monitoring of this process. Aspects of both functional and cognitive testing have also demonstrated utility in prior studies and consequently have been factored into modern proposed methods of determining the athlete's readiness for sport. Further work is needed to definitively determine the optimal method of clearing an athlete to return to sport after ACL reconstruction. Evidence to date strongly suggests a role of a multimodal algorithmic approach that factors in time, graft biology and functional testing in return-to-play decision-making after ACL reconstruction.Level of evidence: level V.

"Fixator-assisted Nailing" Technique for Closed Segmental Tibia Shaft Fracture with Extensive Soft Tissue Injury - A Case Report.

INTRODUCTION: Segmental tibia fractures with extensive soft tissue injuries are rare and surgical intervention is challenging with no definitive treatment strategies. CASE REPORT: A 52-year-old man presented with closed right segmental tibia and fibula fracture with extensive blistering of skin caused due to road traffic accident. Distal pulses were palpable and there were no signs of compartment syndrome and other systemic injuries. In the presence of extensive blistering, a monoplanar external fixator was applied within 24 h of injury. 3 weeks later, skin condition was conducive for internal fixation, and closed intramedullary multi-locking nailing was performed using the external fixator for reduction. Fracture healed at 15 months and patient had an excellent functional outcome with full knee range of motion at 2-years follow-up without any complications. CONCLUSION: Fixator-assisted nailing is a simple, minimally invasive, and easily reproducible technique that is useful in reducing the fracture and preventing axial rotation of the intercalary segment minimizing the damage to the periosteal blood supply. Our case also highlights the importance of temporary external fixator in soft tissue healing and making the skin conducive for internal fixation.

The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis.

Introduction Rates of osteoarthritis and total joint arthroplasty (TJA) are on the rise globally. Periprosthetic joint infection (PJI) is the most devastating complication of TJA. A number of different intraoperative interventions have been proposed in an effort to reduce infection rates, including antibiotic cements, local antibiotic powder, and various irrigation solutions. The evidence on the importance of irrigation solutions is limited but has gained prominence recently, including the publication of a large randomized controlled trial (RCT). Thus, the purpose of this study was to evaluate the effectiveness of various irrigation solutions and pressures at reducing the rates of PJI. Methods A systematic review was performed using the electronic databases MEDLINE, Embase, and Web of Science. All records were screened in duplicate. Data collected included basic study characteristics, the details of the intervention and comparison solutions, if applicable, and rates of superficial and deep infection. A meta-analysis of comparative studies was performed to assess for consistency and potential direction of effect.  Results A total of ten studies were included, of which one was an RCT, eight were retrospective cohorts, and one was a case series. In total, there were 29,630 TJAs in 29,596 patients. The mean age ranged from 61 to 80 years. Six studies compared povidone-iodine (Betadine®) to normal saline, two studies compared chlorhexidine to saline, one study compared "triple prophylaxis" to standard practice, and one study used gentamicin but had no comparison group. The pooled risk ratio for deep infection in studies using Betadine® compared to saline was 0.62 (95% confidence interval [CI]: 0.33-1.19), while for chlorhexidine it was 0.74 (95%CI: 0.33-1.65). Discussion Current evidence on the relative efficacy of irrigating solutions as prophylaxis for infection following TJA remains inconclusive. Imprecision of estimates vindicates the need for a definitive trial to further inform their use in surgical practice.  Conclusion Antiseptic irrigation during TJA with solutions (Betadine®, chlorhexidine) may decrease PJI risk in patients undergoing primary and revision total hip and knee arthroplasties. Wide confidence intervals and heterogeneity among studies, however, render conclusions untrustworthy. Well-conducted RCTs are very much needed to help further investigate this issue.

Effects of carrying school bags on cervical and shoulder posture in static and dynamic conditions in adolescent students.

BACKGROUND: Neck and Back Pain in Students is closely related to the school bags that they carry. There is a dearth of literature in terms of postural changes due to school bags in adolescents, especially those discussing postural changes in static and dynamic loading conditions. OBJECTIVE: To assess the effects of weight, position, and time of school bag carriage in static and dynamic conditions on cervical and shoulder posture in adolescent students. SUBJECTS: Seventy adolescents (35 Females, 35 Males) between 10 and 15 years of age. Methods: Craniohorizontal Angle, Craniovertebral Angle, Sagittal Shoulder Posture, Anterior Head Alignment were assessed in 7 different conditions using Photographic Method and MB Ruler. RESULTS AND CONCLUSION: Significant changes in Sagittal Shoulder Posture and Craniohorizontal Angle were found with unilateral school bag carriage as compared to minimal significant postural changes with bilateral carriage. Maximal significant postural changes, in terms of all outcome measures were noted during loaded dynamic activity. Craniovertebral Angle kept significantly reducing with time. Immediate assessments taken with a school bag weighing 13.5% of the body weight showed a significant decrement in the Craniohorizontal Angle. Even a bag weighing less than 10% of the body weight proved to bring about biomechanical changes, when assessments were taken during the activities that a child has to perform with a school bag (Post Standing, Post Walking, and During Walking).

Rationale and design of the HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) Trial: a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients.

INTRODUCTION: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.

Benign Aggressive Lesions of Femoral Head and Neck: Is Salvage Possible?

BACKGROUND: Benign aggressive bone lesions of the femoral head and neck are mostly seen in young adults and warrant treatment for pain, impending fracture or established fracture, and disease clearance. It becomes challenging to treat them effectively while attempting salvage of the femoral head and yet achieving long term disease control with minimum complications. We describe our technique and experience in dealing with these lesions which can achieve the above-mentioned goals and can be easily replicated. MATERIALS AND METHODS: We analyzed 15 cases of surgically treated, biopsy-proven benign, locally aggressive lesions affecting the femoral head and neck in skeletally mature individuals. All cases were treated with extended curettage through anterolateral modified Smith-Petersen approach along with tricortical iliac crest bone graft (combined with fibular graft in some cases) reconstruction with or without suitable internal fixation. RESULTS: All, except one, patients were available for follow up. The age ranged from 18 to 43 years and the follow up ranged between 24 and 124 months (average 78 months). These included aneurysmal bone cysts (9), giant cell tumors (4), and fibrous dysplasia (2). The indication was pain (8), with impending (2) or established pathological neck femur fracture (5). In all cases, there was satisfactory healing of lesion and timely rehabilitation. Nonunion, avascular necrosis or local recurrences were not seen. The MSTS functional score was good or excellent in all (range 26-29, average 28). CONCLUSION: Benign aggressive lesions affecting femoral head and neck in young and middle-aged adults pose a treatment challenge. A sturdy, lasting reconstruct with acceptable functional outcome and minimal recurrence rate can be achieved by salvaging the femoral head and neck using curettage and reconstruction, obviating the need for replacement at such an early age.

Midterm survivorship and clinical outcome of INDUS knee prosthesis: 5 year followup study.

BACKGROUND: INDUS knee implant has been designed as per the anatomical morphology of the Indian population and has shown good clinical outcome in short term studies. The purpose of the present study was to report the midterm survivorship and clinical outcome of this implant. MATERIALS AND METHODS: Two hundred and twenty three primary total knee arthroplasties in 209 consecutive patients using the INDUS knee prosthesis were prospectively enrolled. There were 145 females (155 knees) and 64 males (68 knees) with a mean age of 69.95 years (range 42-86 years). Annual followup with clinical and radiological examination was conducted, and a survivorship analysis was done using the Kaplan-Meier analysis. RESULTS: Mean followup was 5.8 years (range 5-6.5 years). Eleven patients died while eight were lost to followup and a total of 204 knees were available for followup. The mean knee flexion improved from preoperative 110.4° ± 11.24° (range 60°-130°) to 128.17° ± 8.32° (range 100°-140°) at the final followup. The mean knee score improved from 40.1 ± 10.7 to 90.3 ± 5.34 while the function score improved from 44.35 ± 12.9 to 89.58 ± 7.43. Two patient developed infection and required revision. The Kaplan-Meier analysis reported a survivorship of 98.6% (confidence interval 95.7-99.6%) at the end for 5 years for INDUS knee prosthesis. CONCLUSION: INDUS knee prosthesis has excellent survivorship with a good clinical outcome and low failure rate.

Presence of scapular dysfunction in dominant shoulder of professional guitar players.

BACKGROUND: Playing guitar can cause adoption of asymmetric postures and affect the shoulder's stability. OBJECTIVE: To assess the presence of scapular dysfunction in professional guitar players. METHOD: A lateral scapular slide test was performed at the level of the spine of the scapula and at the inferior angle of the scapula in 20 professional guitar players (age: 18-40 years) and was compared with 20 age-matched non-players at angles of 0°, 45° and 90° of shoulder abduction with both limbs loaded with 0.5-kg weights. Analysis was done by unpaired t test. RESULTS: Scapular dysfunction in guitar players was seen in the form of asymmetric scapula at rest in 25% and dyskinetic scapula in 20% of players. 100% of non-players had normal scapular positioning. Comparison at the level of the spine of the scapula showed no significant difference (p > 0.05), but the inferior angle showed a significant difference at 0° (1.37 cm), 45° (1.93 cm) and 90° (2.15 cm) which was more in the player's category (p < 0.05). CONCLUSION: There exists a marked dysfunction of scapular stabilizers in professional guitar players at the level of the inferior angle of the scapula.

Effects of Yogasanas on osteoporosis in postmenopausal women.

BACKGROUND: Osteoporosis is commonly encountered by postmenopausal women. There is an increased need for a low cost and efficient treatment alternative to address this population. AIMS: To study the effects of integrated yoga on bone mineral density (BMD) in postmenopausal women with osteoporosis. SETTINGS AND DESIGNS: Experimental pre-post study conducted in a community setting. MATERIALS AND METHODS: 30 females in the age group of 45-62 years suffering from postmenopausal osteoporosis with a dual-energy X-ray absorptiometry (DEXA) score of ≤-2.5 underwent a 6 months fully supervised yoga session. All the participants completed the study. Pretraining and posttraining BMD was calculated. OUTCOME MEASURE: DEXA score at the lumbar spine. STATISTICAL ANALYSIS: The study was statistically analyzed using paired t-test to see the significance of pretraining and posttraining effects of a yoga session. RESULTS: Improvement in T-score of DEXA scan of -2.55 ± 0.25 at posttraining as compared to a pretraining score of -2.69 ± 0.17. CONCLUSIONS: Integrated yoga is a safe mode of physical activity which includes weight bearing as well as not weight bearing asanas, Pranayama, and suryanamaskar, all of which helps induce improvement in BMD in postmenopausal osteoporotic females.